Provider Medicare Billing Ripoff

[Walla Walla]

First as a Newby I want to say I love this board. It has saved me a lot of time and effort getting set up. Now for my saga. The following happened to me. I use examples from my own bill:
  Watch out for this trick used by some Equipment providers.  They send you a bill for let's say a AirFit F20 Full Face Frame only and the AirFit F20 Headgear. The bill show's
they're charging  $174.60 for the Face Mask and $40.92 for the Headgear. It than states you owe $43.10 which is 20% of the above prices. The rest of the amount is TriCare/Medicare pending. You send what you owe and your done. Ah not so fast you just got ripped off!
  TriCare/Medicare have set prices that Medicare providers must use. They know what those prices are because they're listed in Medicare's DME Fee Schedules. You can download this Fee Schedule by using a search engine for CMS DME Fee Shedule. (sorry couldn't post link, I'm a newby)      By the way if your with TriCare they use Medicare's Fee Schedule and rules also.
  So let's go back and use Medicare's prices. Head Gear $85.52 and Headgear $18.06. Medicare/TriCare with pay 80% of that and you'll owe 20% which is $20.72.
But since you've already paid them $43.10 they've over charged you $19.38.  Do you think they'll come running back to you with a refund? Yeah me neither.  
   You can of course point out to the Provider their mistake which I have to do. Hopefully they will pay me right away. I know but it could happen really.  The better way is to download the fee schedule so you can look up the charges yourself.  Don't pay more than your required.       
Now my last comment comes with no proof. But the fact that some Providers List charges to Medicare way above what they know they'll  get. Even though they know the schedule fee's and even if they didn't they've dealt with Medicare thousands of times. I think they want people to pay their share based on the inflated prices hoping they never pay attention. Think how many people have been ripped off by this fraud.  Well that's my rant for the night.

[SnoringInOregon]

The cost/payment system is a fraud. But IMO you won't be able to change a thing, so don't get too worked up about it.

Here's my story. I just started a few months ago. I was issued an Airfit P10 mask. I was told that after 1 month I was allowed to buy a new pillow. So I went back and was told my co-pay was 30%, which amounted to $25. Well, surprise, surprise, surprise, if I look up this pillow online from Supplier #1, I can buy it for $19.

My 100% cost online is only $19, as opposed to my 30% cost being $25 from the DME. So where does all the money go? Same with the DreamStation. I paid the DME around $450 as 30% of the cost, people here claim you can buy online for well under $400.

But, let me repeat, don't get too worked up. Sure, try to get back any money you overpaid, but don't stress about it. It's just how the crooked system works.

[Mosquitobait]

I get Medicare. You're not supposed to pay anything until after it's gone through Medicare. You are correct, the 20% is of the contractual price that Medicare pays, not whatever they billed retail. Contact the billing office of your DME and tell them that you were charged based on the wrong price. Yes, you will get it back although they may simply credit your account since you get monthly purchases.

Lincare made a mistake and then promptly credited my account (they discovered their mistake, not me). I didn't have to pay anything for a couple of months by using that credit. You would argue that they were able to 'use' that money during that time, but it's not like I'm going to get more than a penny's interest on that over the course of a couple of months.

Oh, and thanks for the link for that fee schedule. That was interesting.

SnoringInOregon - that is true for a lot of folks. The price they get from an online retailer is sometimes less than the copay through your insurance company. I can only say that a brick and mortar store is nearly always going to have higher costs (read: need more profit) than an online retailer who just needs warehouse space and computers.

[Walla Walla]

Glad Lincare took care of you. I'm not with them though. After a couple of calls I got accounting. They said they did owe me $53.00 and that they would send it. I then had to point out that they owed me $183.00 and the phone got real silent. They finally said that Tricare hadn't notified them yet and they will get back to me. Sorry but that dog don't hunt. I'll get the money though. The point of the post is to warn anyone from making the same mistake I did. If I'm the only one to make that mistake than no harm no foul. But if I helped just one person than it was worth the time to post.

[trish6hundred]

Hi Walla Walla,
WELCOME! to the forum.! I’m sorry you are having problems with your insurance and I hope you get it straightened out.
Good luck to you with CPAP therapy and hang in there for more responses to your post.

[SideSleeper]

Something is wrong here! If you are retired military Tricare4Life is your secondary insurance. Medicare pays the first 80% of the cost they allow (much less than what they are billed) and Tricare picks up the remaining 20%. You should never have to pay out of pocket unless you purchase something from your DME that is not covered. You should never be billed! Tricare automatically pays after Medicare pays there share. These percentages are always the Medicare approved amount. The DME has a contract with Medicare to provide service and accept what they pay. I have a good honest DMA and have never been asked to pay a cent!

[Walla Walla]

SideSleeper your right about Medicare and Tricare for Life after you turn 65. I'm a young kid of 61 so it's Tricare only for me.

[bresach1]

I do medical billing and collections for a living. You never should have been billed prior to the cpap supplier billing Medicare and Tricare. 
Let me tell you what issue I've had lately. My  service provider can't seem to get the hose right and I'm here with a brand new mask, the AirFit F20 and no tubing.  The tubing that they sent me didn't fit my machine and they're telling me that Resmed has this new tubing and wanted me to force it.  They finally agreed to look around for the larger diameter tubing for me but no telling how long that will take them. 

I was using the Amara view but because it didn't do anything for me. It kept leaking at night, I was awoke every hour or two.  I woke up tired I couldn't use it and I haven't used any therapy fpr months. 
Another problem I had with that supplier was that I paid for new tubing because the tubing that they sent me somehow ended up with a gaping hole in it.  They sent me new tubing so I had to buy  for 20 bucks. Supply time comes around and they're telling me that I can't get tubing because my insurance won't pay for it because I just got some. I kept telling them I paid for it my you didn't Bill my insurance but they wouldn't send me tubing with my mask I had to wait a month for them to ship me tubing. Now I got the wrong size and they're having to look for new supplier that carries the tubing for my machine.
I can't just go to another DMV supplier because I would have to have a new sleep study cuz I haven't had one since 2014.  A new sleep study may be my best bet but it may cost me too so it's been a nightmare.

[Mosquitobait]

No problem. It is GOOD to point out these things. Many people are mystified by Medicare. I wait until I receive the paperwork from Medicare that tells me how much I owe before I even consider paying any invoice unless they are supplies I have purchased in the past.

[Walla Walla]

Just an update. After much hounding on my part the provider finally said they would pay me back. It will take 2 to 4 weeks to mail the check though. They said they take care of 7 states and it takes time. Poor Babies! Ripping off so many people is hard work.